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Stable Ischemic Heart Disease (BB Guideline (:red_cross: (AVOID…
Stable Ischemic Heart Disease
effects of Ischemia
mechanical
failure of normal muscle contraction and/or relaxation
transient LV failure
- large segments of the ventricle wall
angina
- transient ischemia
necrosis or permanent scarring
- prolonged ischemia
biochemical
normal myocardium metabolizes FA and glucose to CO2 and H2O. Ischemia leads to anaerobic energy usage
decrease force of contraction
FA ≠ oxidized and glucose is broken down into lactate -->
decrease
IC pH/stores of ATP and creatine PO4 --> impaired cell membrane function
electrical
repolarization abnormalities (T wave inversion)
ST segment depression typical of subendocardial ischemia
ST segment elevation typical of transmural ischemia or infarction
Prinzmetal's (Variant) Angina
due to
focal spasm
or increase coronary tone of proximal epicardial a. without increase MVO2
characterized by
recurrent, prolonged attacks of severe ischemia
30-40yo, pain occurs at rest or awakens pt from sleep, palpitations, severe SOB, explosive in onset, frightening
EKG shows
transient
ST segment elevation
:star:
Management
to treat acute attacks
Nitrates
prophylactic treatment
CCBs
: dose less frequently, <SEs than nitrates;
DHPs or Non-DHP (
Diltiazem or Verapamil
)
combo with
add long acting nitrates if unresponsive to CCBs
Nifedipine + diltiazem
Nifedipine + verapamil
:red_cross:
beta-blocekr
- induce coronary vasoconstriction and prolong ischemia due to alpha receptor
Pharmacotherapy
Antiplatelets
Aspirin
325 mg
chew and swallow for *acute attack
81-162 mg daily
maintenance with SIHD
Clopidogrel
75 mg daily
Antianginals
BB, CCB, Nitrates, Ranolazine
ACEIs
Statins
Stable Angina
Clinical presentation
pressure/heavy weight on chest, crushing, burning, tightness, deep squeezing, gripping, suffocating, aching, vise-like
0.5 - 20 min
at substernal, may radiate but not common
trigger by exercise, walk, garden, cold weather, postprandial, emotional stress and sexual activity
relive by rest and
SL NTG
Classification of chest pain
Typical angina (definite)
substernal chest discomfort with a characteristic quality and duration that is
provoked by exertion or emotional stress
relieved by rest or NTG
Atypical angina (probable)
meet ≥2
typical angina
or
presents with less characteristic symptoms like SOB, jab pain, pain on palpation
presentation?
woman, elderly, diabetes
anginal equivalents included:
SOB, DOE, anxiety, weakness, dizzy, extreme fatigue on exertion, palpitations, indigestion, heartburn
Noncardiac Chest pain
meet 1 or none of
typical angina
characteristic
:star:
Management
Goal:
<130/80
"quality of life"
;
ID risk factors: smoking, HTN, DM control, influenza vaccination
Pharmacotherapy is to
prevent MI and death, reduce symptoms
≥ 130/80
1st line
Beta-blocker, ACE inhibitors, ARBs
add-on:
DHP CCBs, thiazides, aldosterone antagonists
persistent uncontrolled HTN
beta blockers + DHP CCB
MI or ACS history
continue
beta blockers
beyond 3 years (long-term therapy for HTN)
SIDH without HFrEF with MI > 3 years prior
addition of beta blockers and/or CCB
Classification of Unstable Angina
Rest angina
occurs at rest,
>20 min
, within 1 week of presentation
New-onset angina
at least CCS class III severity with onset within 2 months of initial presentation
Increasing angina
previously dx, more frequent, longer duration, lower in threshold
ex. increased by ≥1 CCS class within 2 mo of initial presentation to at least CCS class III severity
BB Guideline
initial therapy for relief of angina symptoms in SIHD
prevent MI and death in SIHD patients with LVSD (EF <40%) and post ACS
use to manage HTN with established CAD
effective single/combo therapy with
nitrates, CCB, and ranolazine
:red_cross:
AVOID
PRinzmetal's Angina
all equality effective, not all FDA indicated